Caring for a Patient Receiving Continuous Wound Perfusion Pain Management

Goal: The patient reports increased comfort and/or decreased pain, without adverse effects.

1. Check the medication order against the original medical order, according to agency policy. Clarify any inconsistencies. Check the patient’s chart for allergies.

2. Know the actions, special nursing considerations, safe dose ranges, purpose of administration, and adverse effects of the medications to be administered. Consider the appropriateness of the medication for this patient.

3. Perform hand hygiene and put on PPE, if indicated.

4. Identify the patient.

5. Close the door to the room or pull the bedside curtain.

6. Assess the patient’s pain. Administer postoperative analgesic, as ordered.

7. Check the medication label attached to the balloon. Compare with the medical order and MAR, per facility policy. Assess the patient for perioral numbness or tingling, numbness or tingling of fingers or toes, blurred vision, ringing in the ears, metallic taste in the mouth, confusion, seizures, drowsiness, nausea and/or vomiting. Assess the patient’s vital signs.

8. Put on gloves. Assess the wound perfusion system. Inspect tubing for kinks; check that the white tubing clamps are open. If tubing appears crimped, massage area on tubing to facilitate flow. Check filter in tubing, which should be unrestricted and free from tape.

9. Check the flow restrictor to ensure it is in contact with the patient’s skin. Tape in place, as necessary.

10. Check the insertion site dressing. Ensure that it is intact. Assess for leakage and dislodgement. Assess for redness, warmth, swelling, pain at site, and drainage.

11. Review the device with the patient. Review the function of the device and reason for use. Reinforce the purpose and action of the medication to the patient.

To Remove the Catheter
12. Check to ensure that infusion is complete. Infusion is complete when the delivery time has passed and the balloon is no longer inflated.

13. Perform hand hygiene. Identify the patient. Put on gloves. Remove the catheter site dressing. Loosen adhesive skin closure strips at catheter site.

14. Grasp the catheter close to the patient’s skin at the insertion site. Gently pull catheter to remove. Catheter should be easy to remove and not painful. Do not tug or quickly pull on the catheter during removal. Check the distal end of the catheter for the black marking.

15. Cover puncture site with a dry dressing, according to facility policy.

16. Dispose of the balloon, tubing, and catheter according to facility policy.

17. Remove gloves and additional PPE, if used. Perform hand hygiene.